Good evening everyone and welcome to tonight's Platinum members webinar. Approaching Polyuria and Polydipsia on a budget. Now we're delighted to have Professor Ian Ramsey with us tonight, who will be leading you on this presentation.
Just before we get started, I'll just do a little bit of housekeeping. I'm sure many of you know the process by now, but for those who don't, if you have any technical issues, please feel free to send us a message, myself and my colleague Lewis are online to help you out. If you have any questions for Ian, he's very kindly agreed to stay on at the end of the talk.
So if you submit them in the Q&A box, which you can find by hovering your mouse over the screen, and we'll get through as many as we can at the end. So without further ado, I'll hand over to Ian Ramsay. Great.
Thank you very much. welcome, everyone. I guess many of you are, enjoying, if that's the right word, the, the heat wave that is affecting, much of England, not so much Scotland.
And I thought I'd start with this nice little, picture here, to get everybody in a sort of cool frame of mind, picture taken in Scotland, during last winter. Anyway, what we're talking about here today is economic medicine. and economic medicine is a recognition that, the textbook solution costs too much for some of our clients.
But we still want to help that animal and the owner, and by helping them, hopefully, we're also, going to, generate a good feeling, amongst our, our staff, And, this, of course, is extremely beneficial to the practise, in the longer run, as well. And I think it's important to recognise that, these cases represent a challenge, but perhaps a different challenge to, the, just doing the medicine, because it's also a challenge of, communication. One economic medicine is not, is dealing with uncaring owners, owners who don't want a solution because they don't want to pay anything at all.
All vets who are trying to cut corners simply, to get through the day quicker. Economic medicine is, is not quicker. It's not less work either, actually.
and it's not about debt collection. it is not necessarily involved in, in shortcuts. All right, let's deal with the elephant in the room.
First of all, what's the professor working at a lovely facility like this doing talking about economic medicine? Well, the reality is that many of the clients who come to me have run out of insurance money. Many of the clients who come to me aren't insured anyway.
And lots of our owners cannot, afford the standard of care, that we might, want, want to, to, to engage in. So actually, economic medicine, very much applies in this building. It's just the where the threshold comes.
And the thought processes that lead to good economic medicine. Are the same irrespective of the threshold. It's just the process and then where you set the cutoff.
So it does not necessarily matter that the cutoff in some of our cases is 2000 pounds or 2. 100 pounds. The process about how you whittle down that which you could do to what you can do is the same sort of process, and it comes from a good working knowledge of medicine.
The better your knowledge of medicine, the better you are at doing an economic job. If you set me the threshold of 100 pounds, I hope I can do a really good job even with that 100 pounds. What economic medicine is about is doing better with less.
my parents, are, are, were bridge players, and any bridge player will tell you that if you have all the best cards in the hand, you will win all the tricks. The good bridge players will win more tricks with good hands, but the really good bridge players, even though they will lose. If the cards are poor, nevertheless get more tricks as they go down.
With the result that at the end of the evening, the best bridge players are actually often identified by their ability to deal with the worst case scenario, not the best case scenario. And knowing the, how to play your cards, as it were, is key, key to this. And the first card that you must be aware of and, and no one is, is, is what is the gold standard.
There's no point in having a discussion about economic medicine without starting from some point, and this is the only logical point to start from. What is the gold standard, of, of diagnosis, and then we can work out how to cut things. And of course, it's important that we, recognise that some of our clients do want the gold standard.
And when confronted with, with the, the little old lady with, with her, her dog, you have to help that person, make a judgement about, where on that spectrum between, zero and gold standard, they, they sit. And I think it's very important that we discuss that with the clients rather than, Assume things, assume because of the way the person's dressed or the car that they drive or the dress that they keep that you know how much they are, can afford to spend. Here are three little old ladies, one, my mother, one, my mother-in-law, and someone who's not related to me.
I'll leave you to guess which is which. Risks And benefits of cost reduction. When we talk about reducing cost to our client, we reduce our confidence.
We become less certain in what we're doing. The animal safety, the safety of the animal may be affected too. We may have to take risks that we would not wish to take with the animal's safety.
It can certainly reduce our total profit as well, but on the other hand, we may spend less time doing it. On the other hand, if we do start to reduce costs, of course, you do reduce the number of procedures, which may itself be a benefit. Providing we are clear in our clinical records about this discussion that we've had with the owner, then, reducing costs undoubtedly reduces our responsibility.
We have been put in a difficult situation. And that as long as we're clear in our clinical records provides us with quite a bit of protection should anything later, later go wrong. And of course it saves the owner money.
I mean, that's the whole point of all this, but it's also been a point to where that although we may save time in terms of our number of procedures, we may have to talk to the owner for longer. It may in fact take more consulting time, even if the time we spend on procedures is right. I think before we start talking about how we go about diagnosis is to ask the question, is, is the diagnosis important?
and, that's both a philosophical question is, do we need a diagnosis at all? And even if we do make a diagnosis, are we going to treat it? Let's say you've listened to this presentation.
You, you go into your clinic tomorrow and someone comes in for a routine vaccination. You see mild alopletia, you ask about PUPD and to cut a long story short, you diagnose Cushing's disease. You prescribe adrenal suppressive drugs, and feeling very good about yourself, and the result is an acute Addisonian crisis and death.
And then the owner comes in. And says, but my dog was never ill before. I think it's important before we start going for a diagnosis is ask the question, would we treat it?
Even if we make the diagnosis, can we treat it? And if we can treat it, will we treat it? And if we can't treat it, or even if we can treat it, we won't treat it.
Why make the diagnosis? Why even attempt it? And then maybe we start to talk about more about symptom alleviation or control, controlling, symptoms rather than, actually making a diagnosis.
The first and most obvious thing when asked to cut costs is if you're not sure what you're doing, get some advice. Advice in the veterinary world is free or very easy to get hold of, very cheap to get hold of, more experienced colleagues, your textbooks, BSABA manuals, your preferred local laboratory, your local referral centre will all provide you with advice and Depending on, the particular, situation, one or more of those may provide you with good ideas about how you can cut costs. For example, your local referral centre, if it's a university, may have certain, clinical trials on the go at the moment that may help.
Your local laboratory may be able to suggest ways that you can cut costs, there. I, I particularly like this, this German proverb here. No doctor is better than 3.
So getting a few people around the table just to think about, what order you're going to do tests and what tests you're going to do, will add, add to that. In addition, now there's, there's quite a bit of networking opportunity, of course, and the Small Animal Medicine Society, for example, runs a online forum on vet surgeon.org where you can put cases up and say, look, I haven't got any money, can't refer the case, what would I do?
What would other people do? The only thing I would say is that if you're going out there to go and get advice is that you should save time and more important by get better results by having the case summarise the results available before you speak or pick up the phone or send an email, have the case details available, give people the case details because it induces colleagues to help you if the details there. If there's very little detail there, no history, no clinical exam, and so forth, it's very difficult to do anything more than write a series of questions, which is somewhat tiresome.
And if you are contacting colleagues outside your own practise, then remember that a picture is worth 1000 words in an email. I, I sometimes see emails and online advice forums where really a picture of the dog could have saved an awful lot of effort. And with modern mobile phones and the internet and so forth, it's very easy to put a picture up there, which will help.
If someone puts a picture up like this to me, I'm already thinking of a particular disease. It's fairly easy to take this case forward, no matter what is being said. The best diagnostic test for polyuria, polydipsia is still a good history and a good clinical exam, and it doesn't need to be hugely complicated.
What it does need to be is very thorough. A logical, carefully constructed history, combined with a thorough clinical exam is still your best tool in, in, in the, in, in your armoury. And, clearly we all forget to ask things when we have dogs.
It's important to back up your history often with a phone conversation to the owner. And again, this is something that is relatively cheap for the owner, is for them to phone you or you to phone them and get more time with them. It also helps because you can then check details, and I will often start the phone conversation with something on the lines of, I didn't quite get what you said about, or I wasn't sure what you meant by.
And then they will induce more history from the owner and sometimes they will contradict themselves because they've had more time to think about it. And so as a result you can avoid expensive mistakes by getting the history right at the start. The most important diagnostic toy of all in your practise is undoubtedly a good quality, clean microscope.
It is simply more diagnostic than anything else, and that's not me just saying that. That's actually being shown in studies looking at Dogs with fever, dogs with, lumps and masses and everything. The one toy that is diagnostic, more things than not is cytology or urinalysis on a microscope or a blood smear on a microscope.
Many, many, many tests can be done in our blood, but, very rarely do they provide you with an absolute diagnosis, whereas, cytology can. And so if you want to get good at economic medicine, get good at doing cytology. Tests are expensive, so we wish to keep the number of tests to a, a, a, a minimum, but Not to, spread those tests out over a long period of time.
The, more tests done over a short period of time tends to work out economically better for owner, the owners than doing lots of little tests over a period of weeks. And that's because you're adding in consulting in additional cons. Consulting fees, additional sampling fees, and so forth.
So it's better to get the owner to save up some money for these tests and to do them in a batch if we can, before we, start doing odd little tests, here and there. This quote from, Halstead about a, a physician, who depends on the laboratory to make a diagnosis is probably an experience, and one who does not say he requires a laboratory is uninformed. And I think that's, that's very true.
a diagnosis, I mean, the definition of a diagnosis ultimately is a guess. All diagnoses are guesses. diagnoses are guesses made at a particular time, at a particular place, on a particular set of information by a particular person.
So some diagnoses are good guesses and some diagnoses are not so good. But all diagnoses I guess is, you will never prove that an animal has or has not got a disease. The only proof is to do a, biopsies or postmortems or things like that.
So, we don't need to prove that a dog has something. Yes, although prove that it doesn't have something. We nearly need these to make us feel a little more confident.
Many, many diagnoses people think, you know, are 100%, but in fact, they're probably only 90%. And with economic medicine, you're going to fall like that figure to fall to 80 or 70% certainty. We need to be aware of the quality of diagnostic tests.
Some tests that we offer in practise are very poor quality. They lack the discriminatory power that we would wish. They lack the repeatability.
They lack the accuracy, and we need to know which tests are good tests and which tests are bad tests. And this is not necessarily that they're always good or always bad, but rather in particular circumstances. So, and this is a graph looking at, the diagnostic tests for Cushing's, but it could be anything really.
What this shows this graph is that as the, frequency within a population rises, So the positive predictive value of one test starts to become so close to the positive predictive value of another test that actually that both tests are equally good, but the negative predictive value in high frequency situations might be completely different. So an understanding of that kind of level is important and if you don't have that understanding, that's where getting the advice from the lab that has done the test is important. Which means that you've got to send the blood to the lab in the first place.
So when you send bloods to the lab, it is, it is good economics, not necessarily because it's actually cheaper to send to the lab, although quite often it is cheaper to send to an outside lab, but because they will back it up with advice, which you cannot in an in-house situation. So it's important to think about that before you select your test. Do you understand the tests that you're doing?
There are quite a lot of in-house tests available now, and it's very tempting to run a lot of them, and I would suggest that 10 in-house tests for thyroids, bile acids, cortisol, and liver enzymes aren't really that useful for polyurea polydipsia. Now I'm not saying that measuring those things might not be useful, but they don't need to be done in an emergency. PUPD is rarely an emergency.
And so you've got time to send it off to a laboratory that will measure these things more accurately. And we'll back it up with advice. So for my client's money, I would rather not do in-house tests but send and wait.
And yes, it takes a bit longer. That's the price they're paying for having a cheaper, a better test for their money. But, the results you get are more reliable.
Doing thyroids and cortisols and bile acids in-house, these things are emergency tests. They are not as accurate, not as repeatable, and not as relevant in some instances as sending off to a to a laboratory. I don't want you to go away from here and say, 00, this is terrible.
all my in-house tests are rubbish. There are tests out there that are not too bad. I mean, the cortisol on a snap test is not bad.
It's a good way of picking up, Addison's, But it is not accurate enough at the higher levels to give you the sort of discrimination that you would need in a dexamethasone suppression test, for example. And, and, and a realisation that what that is useful for and when it's useful for is important. It is important also to understand that what we do for an economic case is, is to reduce the number of tests.
What we should never do is to reduce our, our, our charges. Something for nothing devalues the something, and frankly, reducing the charges for one client is unfair on all those other clients who pay. If you have some method of spreading the load over the time, either by your, your staging of tests or by the owner's, payment of the, the bill, then that's, that's great.
I think it's important to remember that internet pharmacies and, outside, outside laboratories will still charge your practise full price. and, the markups, of course, don't need to be a set percentage for all. I put drugs here, but of course that also applies to all, procedures and tests, routinely putting 100% markup regardless of the price of the test.
It takes as long to interpret, a, a cheap test as it does to interpret an expensive test. So your own practise pricing should look at the markups if this is an issue for you. Certainly, I, I was always taught that if you reduce the price by 50% to 1 client, then you've got to see 5 more at full price, assuming you've got a 10% margin.
And that's a, a shed load of extra work. So let's get down to the nitty gritty here of the polyuria polydipsy dog, a defined list of causes, not that huge. It's not a very long list.
It's not like vomiting and diarrhoea or episodic clips. It's nice and defined for the cat, it's even more defined. But because these things are, are, are the diseases are they, that they are, you need to adopt a logical approach.
You cannot symptom treat a polyuric polydipsy dog. There are few of the diseases on the list that you can make an instant diagnosis from in the consulting room. I guess if you have a dog that has got polyuria, polydipsia, and massive, polycentric lymphadenopathy, you pretty much have a diagnosis, at the start.
There are no nonspecific treatments for PUPD. Some are positively contraindicated. Giving dogs diuretics that already have polyuria, polydipsia is contraindicated.
In many cases, giving steroids is going to make matters worse and delay diagnosis and treatment. So although it's very tempting to, to, in cases of vomiting and diarrhoea, to simply treat the symptoms and don't worry about a diagnosis, I believe that when it comes to polyuria polydipsia, you need to adopt a logical approach to get a diagnosis on economic grounds. Of course, it's important to support the patient while doing this, and that means giving them lots of water and encouraging the owners not to withhold water, I think is quite important.
So, what is our gold standard? Our gold standard is to do a history and physical examination, to, diagnose psychogenic polydipsia in some cases and post-obstruction diuresis and drugs that might have, caused, the polyure polydipsia. We're then going to do a urinalysis to check for diabetes mellitus.
We're then going to routine biochemistry, including a T4, especially in cats, and that's going to be hugely helpful. We're then going to do a haematology and that may help us with the white cell counts. We're then going to investigate Cushing's with a low dose X and an ACTH stimulation test.
We're then going to do diagnostic imaging, radiography, ultrasonography to look for those tumours and more and abscesses and so on. And finally, we're going to finish off with a water deprivation test. That is the gold standard, if you will, for investigating polyuria, polydipsia.
How can we cut that back? Well, the first thing on the clinical history is that I think it's important that an animal with polyure polydipsia has its water intake measured, and the owners can do this. this is something that, that probably in, in a cost unlimited situation.
You wouldn't be so worried about. But I think it's important that you get an objective measurement. Dogs with a polyurea polydipsia of less than 80 mL per kilogramme per day can probably live with it quite comfortably, even though they may be polyuric polydipsy, they'll probably live with it quite comfortably.
Important to rule out dietary environmental influences as well. So, so ask about the foods, ask about the exercises, and go into some detail on that, hunting down extraneous causes. And again, with polyuria, again, I'd be getting my owners to get the records to make sure before we start spending any money that it really is polyuria polydipsia.
Remember too that polyuria may cause urinary incontinence. Of course some cases of polyure polydipsia are so massive that they were going to take these forward straight away. This is a dog with its daily with polyure polydipsia with its daily water consumption.
Clearly in that situation we're not going to spend too much time worrying about some of these more milder cases. Then on the clinical history, I'm going to spend a lot of time talking to the owner about the behaviour, about whether the animal's lethargic or it's had any episodic collapsing episodes, because that's going to take me down a certain pathway. I'm going to ask detailed questions about the appetite.
The increases that they've seen, any decreases that they've seen, because that's one of the most discriminatory questions, in, that, is available to you. And so spend a lot of time to, understanding this. Then to ask the owners about skin changes.
Yes, you're going to examine the dog, but it's important to ask the owner as well about this and particularly go into the, the, the, the medical history as well. So any evidence of drugs being used anywhere, even if you, you think you know what's going on, get the Owner to bring the actual tablets in, find out what they're using. It's surprising how often the owners, the number of different names that glucocorticoids, for example, can be given, you know, the dog's just on some anti-inflammatories, and you assume that that's some sort of non-steroidal, but it actually turns out to be a, a steroid.
. So these are things that, that need to be asked in detail and spend a lot of time on it. As I said, this is not a, this is not a, a, a, a thing to skip on in the case where they are economically challenged. It's more important, not less important to get a good history.
Clearly, a clinical examination also terribly important. we want a full examination. We want it to be written down properly.
And if we're dealing with an economic case, then actually it's more important to keep accurate records. You need more detailed records, not less, in order that you can show that you have done, the best you can. As part of that clinical examination, obviously you're going to spend a lot of time looking at the skin, the lymph nodes, looking for any perent discharges and so forth.
And I would recommend thyroid palpation. Now, clearly, if they come in looking like this, you're going to take things in a very Specific way first. If they have a, a, a, a Volvo discharge, you're going to go off in a, in a different direction first.
And if they've got a, a goitre, then you're going to take that cat off in a different direction. . But let's assume that we haven't found anything really significant on clinical examination.
What's the next stage? Well, I still think your analysis is, is the cheapest and, and, and most appropriate first stage. We want to measure the specific gravity.
We want to look at the sediment under a microscope because it's cheap. And of course we're going to do a dipstick, and if the dipstick comes up like this, well, you've got your diagnosis. The, the, the animal has a high ketones.
It has glucose in its urine, and there's blood in the urine as well. So it's probably got a cystitis, which is secondary to diabetic ketoacidosis. A word on specific gravity.
I usually get this assessed 3 or 4 times in dogs with polyurea, polydipsia, where cost is an issue because I want to be sure that I know what the result is. Specific gravity vary quite a bit in these animals, and it's nice to get an average, so I get the owner to Collect 4 or 5 samples to bring them in, and checked. And if you have, any of those samples where the specific gravity is greater than 1.035, then most causes of polyure polydipsia can be excluded, and this is probably a behavioural issue.
If it's less than 1.008, I'm afraid it doesn't diagnose diabetes incipidus, but if it's more than 1.008, you can safely rule that out.
Glucose clearly very important and if you've got no glucose, then you've got no, no diabetes. So that's an important exclusion on a very cheap test. All the other things, while significant findings are not necessarily diagnostic.
If you really want to save money, perhaps the deposit exam is one that you might drop. We can probably get away without doing that. for most causes of polyopydipsia, you're not going to see something that's going to be diagnostic on a deposit exam.
Biochemistry, again, it's worthwhile thinking about how much value you get out of, biochemistry machines and thinking about, where to send them. Cheap, glucometers, great, but you've already done the urinalysis. So actually, you don't really need to measure blood glucose in these animals.
So we can, we can, ditch those if we've got that, because we've ruled out diabetes mellitus on the urine sample. some of these, in-house analyzers run on whole profiles, and we don't really need a whole profile in this case if we're trying to save money. So we want, really to have analyzers where we can just request one or two tests that are specific.
And the two tests that I really want, want to do, well, first of all, there's glucose. Yes, if, if, we haven't measured anything in the urine, then we should do that. But if we have, we can lose it.
The next one that we really need to know is calcium. So glucose on the dipstick, calcium on the blood, they, they are absolutely the most important. Your rea and creatinine are not as important as you might think, because the azotemia that we, we get just takes us down likely that this is a renal azotemia and probably we will got there earlier, earlier anyway than doing the biochemistry.
So it's less important than the calcium. The calcium you need to measure because the calcium will deteriorate quickly, whereas urea and creatinine will not. But, if the client's got the money, calcium, urea and creatinine would be the three biochemistry tests I'd go for.
What about other biochemistry tests? Well, electrolytes, possibly helpful, might help with patient stabiliser. Phosphate will tend to follow urea and creatinine in most cases.
Thyroid hormone is probably essential in cancer polyure polydipsia, but I would say that if you're trying to save money, that electrolytes and the phosphate are probably not as essential as urea, creatinine and calcium. What about other tests? Well, total protein, almost useless in diagnosing the cause of polyuria polydipsia.
Liver enzymes, almost every cause of polyuria polydipsia will lead to increased liver enzymes, and once they're increased, they're not discriminatory. They don't tell you the difference between Cushing's and liver disease and diabetes mellitus. Bile acids are unlikely to be helpful.
They're not going to tell you very much that, liver enzymes, would, would not. So if you do liver enzymes, you don't need to do bile acids. So get rid of the total protein, get rid of liver enzymes, and possibly, if you do not, if the dog is, is, not losing weight, it's not vomiting, it's not diarrhoea.
Well, it's not in liver failure, so it's probably not got polyure polydipsy because of that you can get rid of bile acids as well. What about haematology? Again, I think a microscope slide and a hematocrit is all you really need.
You don't need to put the, the bloods through haematology analyzer. If you're looking at it down the microscope, that's only going to cost 5 pence for the slide, if that, and 5 pence for the, diff quick, you will be able, therefore, on the basis of that, to see most things. So looking at a slide, we can see that there's a significant shift with the neutrophils, and if there's a left shift there, well, we're probably going to go to a hygienic focus.
If there's a lymphoenia and neutrophilia, then maybe we think about a stress leukogram. Maybe we get lucky and see a leukaemia, and that would cause poly polydipsia. But we certainly don't need numbers for this.
So I'm going to put an orange line through that, not because I don't think you should look at that blood smear, but I don't think you need the numbers so much. You can diagnose that on looking at a blood smear and have a pretty good idea about what's going on. If there's anything significant to find, you will see it on the blood smear.
So where are we at now? Well, we've ruled out diabetes mallets because of the glucose. We can rule out renal failure on the basis of the urea, creatinine.
We can rule out hypercalcemia. So we're already making progress and we've only spent a few pounds at this stage. We can probably rule out liver failure on clinical grounds.
We can probably rule out hyperthyroidism on our T4, and we can probably rule out Addison's if we measured our electrolytes. That leaves us with a fairly short list. If we look at the white blood smears, the, the blood smear, and we can look at, the, the, neutrophils there, we may be feeling that this is not a pyogenic focus.
Maybe we can start to rule that out just on the basis of an absence of a left shift. I agree it's not ideal, but, it, it, it is a, it is a possibility that we could cut that corner. So what are we left with?
These things here? How we going the most likely of those is hyperdrenal corticism, Cushing's without clinical signs, other clinical signs, is the most likely cause of PUPD at this stage now. So we would probably go and talk about doing some sort of diagnostic testing.
Now, if you have a dog that looks like this, clearly an ACTH stimulation test would probably be your best test here because it is specific. If you wanted to save some money, you could just measure the post ACTH cortisol, so you, you would save quite a bit of money there. But the, the, the clinical signs of the dog probably have led you to this stage further.
So, so you need to think about . Doing a a a a specific task. One thing I would say is that I see a lot of people when cost challenged cases, they see a dog that looks like this.
They do an ACTH stimulation test straight away without doing any other test. And although that is, is, is a, a cost saving, it may appear, I think the risk of that dog having diabetes or significant concurrent kidney problems which will affect your treatment is sufficiently high that at the very least you should measure glucose, urea, creatinine. In a dog, which you are thinking has Cushing's disease, you really do need to pick up those confounding factors before you start offering treatment to the owner.
For the dogs that don't have obvious other signs, so what we're thinking of here particularly is cutaneous signs, then it's probably tempting to go and do a low dose dexamethasone suppression test. This has the advantage of being more sensitive and, and therefore is better at excluding Cushing's. However, you can save some money on this, first of all, by making sure that the owner sits with the dog during the day, so not in your kennels, and secondly, by not submitting the 3 hour sample, because the 3 hour sample is only there really to tell the difference between pituitary dependent and adrenal dependent disease.
And as, this, this is a cost challenge chase, you're not going to operate on this dog anyway. So, the 3 hour sample is probably, not necessary. If you really want to save some money, you could, not submit the zero hours sample.
There is a disadvantage of this, and, and that is that knowing the zero-hour sample gives you some measure of confidence about the 8 hour sample's veracity. It's really important, the more you cut down on these tests, that it's you that administers the examethasone and you make sure that it goes IV and that you know what's going on, in that dog. So saving all this money will lead us to hopefully then having some money left to do some diagnostic radiographs.
Clearly, if we found something specific on our clinical examination, we're going to do specific radiographs for that. But if we have not found anything so far, then really getting some survey radiographs. Particularly of the chest to look for non-alpable lymph nodes, metastatic disease, and so forth.
And The abdomen, particularly in big dogs, because we can miss masses in big dogs. Cats, I can trust that any significant mass in a cat's abdomen, I can find on palpation, whereas a big dog, I'm going to struggle with. So I think it's important, and this is a classic case example.
This, this was a Rottweiler that presented with polyuria, polydipsia cost challenge situation. We did all the things that we've described and we took finally a radiograph and what you can see here is a very large sublumbar lymph node. To this day, I don't know what the cause of that, large lumb sublumbar lymph node was, but I'm pretty sure it was a, a tumour.
This was a metastatic lesion. A fine needle aspirator after the animal died confirmed that this was a carcinoma in here, but this explains what's going on in this dog. And without a radiograph there was no way that we could have felt that in a large dog like a Rottweiler, you would not feel a sublumbar lymph node like that.
What about ultrasound? I think that's, you have to be, realistic about the value of, of survey scans in, in animals with, non-specific clinical signs. There are many non-spec.
Specific changes on ultrasound, particularly in older dogs, and it can as much mislead you as it can diagnose a condition. However, if you know what you think is going on, so you think, for example, the animal has a pyometra or you think it has kidney disease, then, using the Ultrasound to better characterise that disease, which you already know or already suspect, ultrasonography is invaluable. And the reason why I say, say that there's limited value in survey scans, and that is because the real value of ultrasonography in a case of polyurea polydipsia.
Is looking not at the liver and the kidneys, the spleen, the bladder, and the uterus, but looking at the lymph nodes, the non-palpable lymph nodes, looking at the adrenals, and, perhaps even looking at the GI tract. And, and those are not easy. And we have to be sure that when we do the ultrasound that we can identify those.
And this is one place where, getting an external ultrasonographer to do an external ultrasound may be a useful use of the, of the client's money if they can afford that much. And that's one time when I would get, an external person to come in, and help, if the owner can afford it. Because something like this will alter what you're thinking.
Here's the left kidney, here's the left adrenal gland. You can't, you can't palpate this on, on this boxer, and actually on, on on radiography, it's not that clear either. So it's, there are definite values in doing ultrasound, but we have to be able to identify those adrenal glands.
So what happens if so far we've got nowhere? This is a fairly rare case now. History and our physical exam are negative.
Our routine bloods are negative. We've excluded Cushing's, radiographs, ultrasounds are all negative, and now we've actually spent some money. Well, let's go back and have a look and say, well, we've ruled out diabetes, we've ruled out renal failure, we've ruled out Cushing's, hypercalcemia, tumours, liver failure, yogenic foresite, hyperthyroidism, Addison's disease.
What we're left with is diabetes incipitous and psychogenic polydipsia. And for this, really, we have to go back and talk to the owner very carefully because psychogenic polydipsia is often diagnosed on history. It may not be the first history that you take, but it is something that can be, often in, found in young dogs housed in groups that are competitively drinking.
It can be owner induced, so the particularly attentive owner who's, rewarding drinking, behaviour. it, it is, it can, can induce, a psychogenic polydipsia. And psychogenic polydipsia is something that, we do see in human beings, when we engage in, in competitive drinking competitions.
So why not dogs? Diabetes incipitous are on contrast, will always be severely polyuric polydipsy, and they may become dehydrated. And on these occasions, we probably are going to diagnose this with a DDAVP trial.
Water deprivation tests are terribly expensive. They're not very accurate. They're not very reliable.
and, and to do this, we will have the owner come into the hospital, and give us the dog and we will hold. Onto the dog whilst that the water is withheld for 3 hours. We'll get a urine sample for specific gravity at the end of that.
We'll inject DDAVP and then get a urine sample some hours later. And I think if you fail to get concentration with an injection of DDAVP, then you've either got nephrogenic diabetes and, sorry, you've got nephrogenic diabetes incipi if you fail to get a, a, a, a response. If you do get a response, from, an injection of DBAVP then psychogenic polydipsia is still possible, but, central diabetes is more likely.
So in summary then, if we are asked to cut costs. The first and most important thing is to have a good discussion with the owner about all the options and the costs of cost reduction because cost reduction comes with a price. It may not be financial.
It may be in terms of patient safety. It may be in terms of time, and therefore the owners may have to put up with a dog with polyuria polydipsia for a while longer because you're going to take more time to make the diagnosis. In terms of making the diagnosis, we need to rely on clinical signs more and clinical pathology less, which inevitably leads to a degree more, more of a risk.
Check the urine specific gravity more than once. Really important to do that early on. Biochemistry remains your best chance of making a diagnosis, and it's important to check for other significant problems, but I hope I've shown you how you can cut the number of tests down and so save some money.
ACTH stimulation tests versus low dose dexamethasone suppression tests, that's probably a more detailed and more convoluted conversation. But basically, if the animal has clinical signs, we should use the ACTH stimulation test, whereas if it's only got polyuria, polydipsia, we should probably, just do the low dose DEX. It's important to ask at each stage, can the owner of afford to treat this?
Is it fatal? And if it, if the answer to both of those is no, then why test for it? If the answer is no, yes, then it is still important to test for it because you don't want to carry on, trying to, diagnose things if the outcome is going to be, a fatalist.
So I showed you the ideal. Where do we, where do we sit now? Well, we still need to do that history and physical examination, but we're going to do it many more times and we're going to do it, even more detailed.
We're going to, to do a urinalysis just as we would any normal case. We're going to Do a routine biochemistry, but we're going to cut out some things. We're going to cut out the electrolytes, because that's not likely to discriminatory.
We're going to cut out the phosphate because that's not going to help us very much. We're going to cut out the liver enzymes because there are, we will use the history in the physical exam to diagnose, liver disease. We can reduce the amount we spend on, on haematology, so we don't do a full haematology, we do a blood smear and all we're looking then at the differential white blood cell count.
We're going to exclude Cushing's disease by one measurement of cortisol, probably an 8 hour postex, as an exclusion test, or if we include it, then, an ACTH stimulation test and use the post ACTH cortisol. We're then going to do, save the money as much as we can for that diagnostic imaging because there's no cheap way of doing an X-ray or an ultrasound, and we have to think, how we're going to do it. The bigger the dog, the more important it is to do radiographs, the, more idea we have.
About what might be going on, the more important it is to do the ultrasound. So we need to decide which comes first. And finally then, if all this fails, we can do a DDAVP trial.
And if we're going to do that, then it's important to measure the specific gravity, to try to make that distinction. So hopefully, if you follow my logic through all of this, you will have saved the client considerable sums of money. But it comes with a price, and the price is that you have increased the risk.
You've increased the risk that you may miss something. You've increased the risk you may make a diagnosis, which isn't correct, and you may cause the animals some problems, but that's the price you pay when you cut costs. And I think therefore it's important that owners understand that and we have the discussion with the owners and that we record that discussion in the notes.
So that if there are any questions later on, we have put down our thinking very clearly in the notes about what's going on. I hope that talk was useful. I'd be happy now to take, any questions, and perhaps have a, a, a, a discussion, about options here, at this stage.
Thank you very much. Wonderful. Thank you very much, Ian, a very useful presentation.
I'm sure everyone would agree. As we, as we mentioned, if you do have any questions, please submit them into the Q&A box that you should be able to find on screen. I've got a couple coming in.
Just before we do go on to the Q&A, session, we are actually running our annual community feedback survey at the moment, where we'd love to hear everyone's feedback about what we're doing well, what we can improve, what you'd like to see more of. And there is actually a large cash prize available at 1000 pounds. So please do, check your emails or check the blog on the website for more details.
OK, on to the questions. You mentioned, Ian, about checking your own specific gravity more than once. Claire's asking, should we check that at different times of the day?
Yes, yes, particularly, particularly if there's any doubt in your mind about psychogenic polydipsia, because what you can have is a situation where the dogs will gorge themselves with water during the day, particularly the owners at home. Sorry, particularly the owner's not at home. They gorge themselves with water drain.
There's one water bowl, 2 dogs, owner's away, comes back, and there's puddles everywhere, and then there's puddles carrying on through the evening, and that's what the owner remembers. But if you get the air and off them first thing in the morning, you find that they're fine, the specific gravity is high. So, yes, I do go for different times of the day, yes.
Perfect, thank you very much. And Greg's asking, would you charge for your analysis, for example, Euroys and USPG as, one feline specialist has said we shouldn't charge for this. Well, I'm glad that feline specialists thought that they could dictate practise policy.
My answer to that is that it's a matter of your practise policy. You need to buy a refractometer. If you work in the University of Glasgow, then you'll know that those refractometers get broken quite regularly, actually.
They need to be replaced. They need to be maintained. Somebody needs to service them.
Somebody needs to make sure that, you've got, in-date urinalysis sticks on the shelf, and, they, each of those sticks cost money. And you've got to spend the time, the nurse's time, doing that dipstick and recording the results and interpreting the results. So my feeling is you should always charge for doing something like that, whether you charge a lot.
Now that's a different matter, but I, I I'm not comfortable with the idea of not charging, I mean, unless of course you have, you know, a feline chronic kidney disease clinic and you do a urine dipstick on every case that comes into that clinic, then it can wrap it into your consulting price if you wish. But no, I, I, I think that there's very clear reasons why you should charge. Yeah, it's very good advice.
Thank you. Sue's or Sue's, commented saying, an excellent plan to follow in these challenging cases. Very useful, thank you.
But it's also useful to think outside the box. An owner bought in a dog with PUPD before asking any questions, I noticed a huge testicular testicular tumour. Advised to deal with this first, and on the 10th day, stitches out visit, the owner reported that the PUPD had gone.
The tumour must have been hormonally active. Yes, but that, that, that just emphasises my point about a good history and a very thorough clinical exam. Definitely.
I don't think, I don't think it's anything outside the box to notice a testicular tumour. Yes, in a dog with PUPD with a large testicle, of course one would remove it. Sattoli cell tumours are known to cause PUPD and, and, they may not cause anything other than PUPD in some cases.
Yes, good comment there, thank you very much. Danielle was asking, do you see a lot of dogs with hyperthyroidism? No, but when, but we see a few, and when you see one, you just don't think of hyperthyroidism, so it can end up being quite a long and expensive business.
So, again, just a tip, you know, palpate the dog's thyroid, palpate the dog all over, palpate the neck. Even if it's not a, a, a thyroid tumour, there could be a, a large, A thyroid cyst or or something like that. Yeah, I, I, I mean, it's not common, but that again comes back to a good thorough physical examination.
And if you do have a PUPD dog with what looks like a lump near its thyroid, I would consider that to be the most likely cause of the polyure polydipsia and should be dealt with. About, if I can give you a figure, of dogs with thyroid tumours, about 10% are hormonally active. About 10% are sufficiently destructive.
They actually cause hypothyroidism, and the other 80% are just nasty, malignant, aggressive tumours that can invade, surrounding structures. It's a very different biology to, feline hyperthyroidism and feline thyroid tumours. Interesting.
Thank you. Steve's asking, is post-obstruction diuresis a persistent problem and requiring treatment? The reason I put post-obstruction diuresis there is that, yes, it can, it can, it can last for a week or two, and sometimes you don't see the obstruction.
So, so cat, particularly obviously relates to blocked cats. Blocked cat relieves itself of its, you know, becomes obstructed. Somehow manages to relieve itself of the obstruction, but then you get the diuresis and the polyure polydipsia afterwards, and they, the owners may not have noticed.
So you see this polyure polydipsic cat acutely. So it's important to ask about litter straining and so forth. It's, it's not a big, big one, but it's the only way sometimes you can diagnose that is on a history, so which is why you rule it out first of all.
Brilliant, thank you. Raquel said great and super useful talk, so thank you. And she knows that it's rare, but how about atypical hypoadrenal corticism?
OK, well, OK, so be careful here. Atypical hypoadrenal corticism is a cortisol deficiency. It may be associated with mild polyuria, polydipsia, but other signs would predominate.
So, the vomiting, the diarrhoea. The general lethargy, and I've never come across, although Addison's is listed as a cause of polyuria polydipsia, I've never come across an Addisonian dog presenting for just polyurea polydipsia. Now I'm not saying it never happens.
I'm sure somebody's going to say, oh, I had a case. Well, well, great. But if you look at the literature, out of the thousands of dogs with hypoadrenal corticism, very, very few ever have just polyure polydipsia.
I wonder whether Raca actually meant atypical Cushing's, that is to say, Cushing's disease that presents, like a god with Cushing's so there's polyurea polydipsia, but that the ACTH stimulation test and the low dose dexamethasone suppression test is negative. Atypical hyperadrenal corticism. Yes, that is a difficult diagnosis.
On the other hand, in an economic medicine situation, it's not an important diagnosis because the dog will live with that condition for a very long time. So atypical Cushing's is now regarded as being mild Cushing's. There's, there's some data backing that up.
They show that the cortisol levels are increased but not as increased in the other dogs with typical Cushing's. So probably the degree of polyure polydips is going to be less. So usually you will have time to make this diagnosis.
OK, great. Thank you. Interesting comment, Greg, regarding the The specialist says maybe the specialist who charges £200 per consult can afford not to charge the client, which makes them look very caring in the eyes of the client.
Oh yeah, that, that just puts it into, yeah, that's puts it all into a big package. Yeah, yeah, but I, I don't think that, that, that's . Relevant and I don't think that's a relevant thing to do and be doing in primary care practise to charge huge consult fee in primary practise and include a load of tests in that because there's going to be lots of primary care cases where they don't need those tests.
Yeah, absolutely. And ACTH used to be really cheap to buy. Do you know why it's so expensive now?
Depends where you're you're coming in from. The, ACTH in, in the UK is now reasonably cheap. It, it, the, the old ACTH we used to use in the UK was Senna and, and, well, it was really, really cheap.
It went off the market and, we had to import it from the USA and that was frighteningly expensive. DeA then brought out a veterinary special, which was much cheaper. Different parts of the world are going through similar problems with ACTH.
I mean, my view is that if ACTH is really expensive in your country, then don't do ACTH stimulation tests except for cases where you suspect adolescents. and, and, and there you need to use that, but it's a once in a lifetime test. There's no reason to be doing an ACTH stimulation test if it's expensive.
On, on dogs with Cushing's or polyurea polydipsia, you would just go to the low dose decks. OK, thank you. Ian's commented saying, prior to having in-house analyzers, I always liked strip, I always liked test strips that were available to test BUN in whole blood.
I think they're called Eurostrat tests, but they may not have been. The results were red when the test strip went from a pale yellow to a deep blue colour. Not only were they spectacular, to a Scot, they were fabulous because they were cheaper.
Well, apart from that comment about the, the, the Scots, yes, I, I, I remember those two, good, good days. How, how useful, were they? I think they were, something you could show the client that said, this dog's really azotemic, but frankly, the urine smell on the breath usually gave it away by that stage.
The, mild azotemias were missed, and they were not that. Repeatable. So, so that it was very, you know, one day it would be your ear would be 14, you'd take the blood and you measure it again and actually it was only 24, yeah, you know, it was a yeah or nay.
Yes, it, it was good. I don't even know if they're still available. I'd, I'd like to hear it from Ian if they, if they're available.
I don't think anyone deluded themselves about how accurate they were and they were quite nice, for, for some, for some things. but, I, I, I, I don't know if they're even available actually. No problem, thank you.
Kama's a great useful talk. Thank you. Sorry if it's a silly question, but how long can you leave a urine sample before doing autistic?
Should it always be kept at room temperature? Right, OK. Well, first of all, no, it shouldn't be kept at room temperature.
It should be if you get a urine sample, stick it in the fridge and do the, the, the dipstick within 24 hours. Maybe you can get away with 48. But, you're not going to, adversely affect things too much.
I. I'm sure there is a study somewhere, Carmen, but, I don't know it off the top of my head. I think if you look on, on PubMed, I'm sure there's a, there's a, there's a, some, some resident has done a project on this, but the way we do it, I, I, I would, I would take it, stick it in the fridge, stick it in the, and do it within 48 hours.
Be surprised if there's not a study on it it's out there somewhere. Rob said, I was once advised an animal might have had medullare wash out. Is there such a condition?
Oh, good question. Controversial question, Rob. Mulri washout, does it exist?
If it does exist, is it important? Medullori washout is, is a situation where an animal that's had very severe polyuria polydipsia for some time has, cause solute loss, and now the loop of Henley doesn't work properly. It's actually the basis of the polyuria polydipsia of Addison's disease.
So I do think it's possible to get medullary washout. aldosterone deficiency would cause medullary washout. How common is it?
I think it's really rare and in, in, in, in the In most normal dogs it's very hard. I know there have been some experimental studies, and it's not nice to think about this, but where they've forcibly given lots and lots and lots of IV IV fluids to dogs, IV water to dogs to try to, they were trying to do was volume overload them to see if they could induce heart failure, but they never were able to demonstrate meduri washout experimentally, meaning that at least over a short period of time you couldn't do it. So does it occur?
Yes, I think it probably does. It's something that the reason why we would then withhold water for about 2 to 3 to 4 hours before we start measuring specific gravity if we're going to do a DDAV response, it should respond very quickly should Madari wash out, providing the animal has enough solute. I, I think the, the, the that is assuming that the sodium potassium concentrations in the animal are normal, then meduri washout is not generally an issue.
But if you don't know your sodium potassium concentrations, then it's certainly possible for the hyponatraemic dog, to perhaps develop meri washout. Excellent, thank you very much for that, Ian. Just finally then, Ian, in response to your question has said I've still got some of the tests, but I can probably find leeches as well if I look on.
Good one, Ian. Very good. Thank you very much.
Well, that's it for tonight. Thank you very much, Ian Ramsey, again, for a wonderful talk and thank you all for joining us and we'll see you on the webinar soon. Thank you very much.
Goodbye. Good night.